Inspection·October 15, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to document, follow up and resolve grievances for one (R7) resident out of five residents reviewed for grievances in a sample list of eight residents. Findings include: R7's Minimum Data Set (MDS) dated [DATE] documents R7 as moderately cognitively impaired. This same MDS documents R7 requires maximum assistance from staff for personal hygiene and is completely dependent on staff for assistance with eating, oral hygiene, toileting, showering, dressing, bed mobility and transfers. On 10/14/25 at 8:30 AM, during the entrance conference, V2 (Interim Director of Nurses/DON) stated the facility has not had any family concerns and/or grievances for the past three months. V2 stated there is no grievance log or grievance reports. On 10/14/25 at 10:20 AM, V16 (R7's Power of Attorney/POA) stated on 9/7/25, V10 and V11 (Certified Nurse Assistants/CNAs) assisted R7 to R7's bathroom toilet. V16 stated R7 was being transported from her bed to the toilet using a total body mechanical lift using a toilet sling. V16 stated during the transport back from the toilet to the bed, R7 continued to have a bowel movement. V16 stated R7 was not positioned correctly in the sling and was ‘screaming in pain'. V16 stated R7 was about a foot away from the toilet. V16 stated V11 (CNA) then pushed a small garbage can under R7. V16 stated R7 was forced to have a bowel movement in a garbage can as she was screaming in pain due to poor positioning. V16 stated V16 has had multiple conversations and ongoing electronic mail (E-mail) with V2 (Interim DON). V16 stated V16 asked V2 to not have V10 and V11 CNAs in R7's room and/or providing any cares for R7 after the 9/7/25 incident. V16 stated both V10 and V11 have provided cares since that date (9/7) and when V2 was informed, V2 responded with ‘(V10, V11) are not (R7's) primary CNAs so that is okay'. V16 stated she asked if there was someone else to speak to about ongoing care concerns and the staff ‘neglecting' R7 and was told by V2 that no one else would be able to do anything. On 10/14/25 at 1:20 PM, V1 (Administrator in Training/AIT) stated she was made aware of R7's family concerns on 9/7/25. V1 stated V2 (Interim DON) informed V1 that V2 is ‘taking care of that situation' and nothing else needed to be discussed and/or elevated to a grievance report. On 10/14/25 at 2:20 PM, V2 (Interim DON) stated V2 has worked ‘closely' with V16 (R7's POA). V2 stated V16 has had multiple concerns about the lack of care for R7. V2 stated V16's concerns were never reported to V21 (Grievance Officer) due to V2 did not think V16's concerns needed to ‘rise to the level of a grievance'. On 10/15/25 at 12:05 PM, V21 (Grievance Officer) stated grievances can be brought forward from residents, resident representatives, staff, visitors or anyone who has a grievance. V21 stated she has not received nor been made aware of V16 (R7's POA) concerns. V21 stated V16's concerns would ‘rise to the level of a grievance' and should have been brought forward.The facility policy dated October 19, 2022, titled Grievance Policy documents It is the policy of this facility that each resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their facility stay. Voicing grievances is not limited to a formal, written grievance process but may include a resident's verbalized complaint to facility staff. Event ID: Facility ID: 145381 If continuation sheet Page 2 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clark-Lindsey Village 101 West Windsor Road Urbana, IL 61801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect one (R7) resident's right to be free from abuse and neglect by staff members (V10, V11) out of five residents reviewed for abuse and neglect in a sample list of eight residents. R7 was not provided basic cares such as repositioning and incontinence care timely. R7 was made to cry, scream and yell out in pain as staff refused to assist and reposition R7 during incontinent cares. Findings include:R7's Electronic Medical Record documents medical diagnoses as Gastrointestinal Hemorrhage, Protein-Calorie Malnutrition, Alzheimer's Disease, Dementia, Anxiety, Difficulty in Walking, Need for Assistance with Personal Cares, Cognitive Communication Deficit, Crohn's Disease, Cervical Disc Degeneration, Diverticulitis of Large Intestine, Diabetes Mellitus Type II, Dysphagia, Unsteady on Feet and Repeated Falls.R7's Minimum Data Set (MDS) dated [DATE] documents R7 as moderately cognitively impaired. This same MDS documents R7 requires maximum assistance from staff for personal hygiene and is completely dependent on staff for assistance with eating, oral hygiene, toileting, showering, dressing, bed mobility and transfers. R7's Care Plan interventions dated 7/15/25 instructs the staff to anticipate and meet R7's needs and encourage frequent position changes as condition allows.On 10/14/25 at 10:10 AM, V16 (R7's Power of Attorney/POA) stated the facility is ‘short-staffed'. V16 stated R7 has to wait 30-60 minutes sometimes for staff to answer the call light. V16 stated R7 has cameras placed in her room that record 24 hours per day. V16 stated the personal cameras are reviewed daily and ‘many times' sees that staff do not enter R7's room for multiple hours at a time. V16 stated R7 is incontinent of urine and bowel and needs to be ‘at least changed' (provided incontinence care) every two hours. V16 stated on 9/7/25 V10 and V11 Certified Nursing Assistants/CNAs) assisted R7 to R7's bathroom toilet. V16 stated R7 was being transported from her bed to the toilet using a total body mechanical lift using a toilet sling. V16 stated during the transport back from the toilet to the bed, R7 continued to have a bowel movement. V16 stated R7 was not positioned correctly in the sling and was ‘screaming in pain'. V16 stated R7's entire buttocks and hips were showing below the sling and both of R7's arms were forced above her head due to R7 was sliding out of her sling. V16 stated R7 was about a foot away from the toilet. V16 stated she yelled at the staff (V10, V11) to assist R7 back on the toilet to readjust R7's sling, reduce R7's pain and allow R7 to finish having her bowel movement. V16 stated V11 (CNA) yelled at V16 to ‘get away from us', ‘you need to go sit down' and ‘we (V10, V11) are not moving (R7) anywhere, we know what we are doing, now go sit down'. V16 stated V11 (CNA) then pushed a small garbage can under R7. V16 stated R7 was forced to have a bowel movement in a garbage can as she was screaming in pain due to poor positioning. V16 stated R7 would think this would be ‘absolutely horrid' and be ‘humiliating' to have to have a bowel movement in a garbage can. V16 stated R7 would never have a bowel movement in a garbage can and would be ‘mortified' at this entire incident. V16 stated R7 was ‘hysterical' and ‘afraid' during this transfer back to her bed due to R7 was afraid she was going to fall and was in so much pain. V16 stated V10 and V11 CNAs left R7 on her bed without finishing incontinence care or positioning R7 safely in bed. V16 stated They (V10, V11) just left (R7) there with p*** (expletive) on her. They (V10, V11) walked out of the room and did not come back. V16 stated the facility ‘neglected' R7 by not providing perineal and/or incontinence care, not repositioning R7 for extended periods of time and refused to provide pain relief by not transferring R7 as V16 requested the staff to move R7 to a more comfortable position. V16 stated the staff are ‘belligerent and confrontational' when V16 asked for assistance. V16 stated V15, V17 (R7's private caregivers) and V16 provide direct cares, repositioning, feeding assistance and administer medications to R7 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145381 If continuation sheet Page 3 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clark-Lindsey Village 101 West Windsor Road Urbana, IL 61801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Actual harm Residents Affected - Few due to the staff are ‘neglectful' by not entering R7's room and force R7's family and caregivers to provide all of the services themselves. V16 stated We (V15, V16, V17) have to do everything for (R7). We (V15, V16, V17) provide all the cares, we administer all of her medications, we reposition (R7), we feed (R7), we provide oral care, nail care, skin care, etc. for (R7). We have to do everything because the staff neglect (R7) on a daily basis. We turn on the call light and no one comes for hours. We have cameras in (R7's) room that shows NO staff enter for six or eight hours or more. Anything (R7) needs, we (V15, V16, V17) have to go get and bring to (R7's) room. We even have to go get her medications because the nurses won't bring them. V16 stated the facility provided packets and a gallon jug of thickener and a device for V15, V16 and V17 to crush R7's medications. V16 stated the facility allows the staff to neglect R7 by knowing that the staff are not providing R7's cares. V16 stated V16 has had multiple conversations and ongoing electronic mail (E-mail) with V2 (Interim Director of Nursing/DON). V16 stated V16 asked V2 to not have V10 and V11 (CNAs) in R7's room and/or providing any cares for R7 after the 9/7/25 incident. V16 stated both V10 and V11 have provided cares since that date (9/7) and when V2 was informed, V2 responded with ‘(V10, V11) are not (R7's) primary CNAs so that is okay'. V16 stated she asked if there was someone else to speak to about ongoing care concerns and the staff ‘neglecting' R7 and was told by V2 that no one else would be able to do anything. On 10/14/25 at 1:20 PM, V1 (Administrator in Training/AIT) stated she was made aware of R7's family concerns on 9/7/25. V1 stated V2 (Interim DON) informed V1 that V2 is ‘taking care of that situation' and nothing else needed to be discussed and/or elevated to a grievance report. V1 stated all allegations of any type of abuse should be reported and investigated. V1 stated R7's allegation was an isolated incident and has not had any other concerns brought forward by other residents or resident representatives. V1 stated the facility did not follow their abuse policy. On 10/14/25 at 2:20 PM, V2 (Interim DON) stated V2 has worked ‘closely' with V16 (R7's POA). V2 stated V16 has had multiple concerns about the lack of care for R7. V2 stated all residents should be visualized every two hours. V2 stated R7 should be repositioned and offered incontinence/perineal care at least every two hours. V2 stated V16 (R7's POA) is very involved in R7's care but the facility should be providing the cares, medications, assistance with transfers, etcetera. V2 stated V10 and V11 (CNAs) came to V2 a week after V16 (R7's POA) sent V2 DON an electronic mail (E-mail) on 9/7/25 reporting V16's concerns and asking for V10 and V11 to not care for R7. V2 stated she had already responded to V16 on 9/8/25 but had not spoken with V10 nor V11. V2 stated V10 and V11 came to her stating there was an incident on 9/7 involving R7. V2 stated V10 and V11 stated they knew V16 (R7's POA) would ‘tattle' on V10 and V11 and they (V10, V11) were reporting themselves. V2 stated she informed V10 and V11 at that time that neither V10 nor V11 should be R7's primary caregiver but could enter R7's room to provide cares. On 10/14/25 at 3:15 PM, V9 and V11 (Certified Nurse Assistants/CNAs) transferred R7 from her recliner to the toilet and back to R7's recliner using a total body mechanical lift with a toilet sling. On 10/14/25 at 3:50 PM, V11 (CNA) stated V10 and V11 (CNAs) transferred R7 on 9/7/25 from R7's bed to the toilet and back to R7's bed again. V11 stated during the transfer R7 was ‘screaming, yelling out and carrying on'. V11 stated she did not think anything of this due to R7 ‘screams every time we transfer her'. V11 stated R7 was finished using the restroom so V10 and V11 began transferring R7 back to her bed. V11 stated R7 began to slide down in the sling. V11 stated R7 continued having more bowel movement during the transfer. V11 stated (R7) was s******* (expletive) all over the floor. Some almost got on my shoe! (V16) was screaming at us (V10, V11) to lay (R7) down in bed so she could be more comfortable and finish getting cleaned up in bed. I told (V16) she needed to get out of my face and go sit down. I can't do my job if (V16) is yelling at me. I pushed a trash can under (R7) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145381 If continuation sheet Page 4 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clark-Lindsey Village 101 West Windsor Road Urbana, IL 61801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete and let (R7) finish p****** (bowel movement/expletive) into the trash can so it didn't get on my shoe. Once (R7) was done p****** (expletive), we (V10, V11) transferred (R7) back to her bed and left the room. (R7) kept crying and screaming. (V16) kept yelling at us (V10, V11). We had enough of it. I guess (V16) finished getting (R7) cleaned up because we (V10, V11) were done with (V16). On 10/14/25 at 4:00 PM, V16 (R7's POA) provided camera footage showing on 10/14/25 at 6:01 AM an unknown (CNA) provided perineal care for R7, at 8:00 AM Speech Therapy provided Speech therapy with R7 while R7 was laying in her bed, and there were no other recordings of any staff entering R7's room until 3:10 PM when V9 (CNA) answered R7's call light. Through direct observations, R7 was in her room and staff did not enter R7's room from 10:30 AM-3:10 PM. The facility policy dated February 20, 2025, titled Abuse Prevention and Prohibition documents all residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of resident property and exploitation, including abuse facilitated or enabled through the use of technology, photographing and recording of residents. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness, or in the deterioration of a resident's physical or mental condition. The facility staff should identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. Event ID: Facility ID: 145381 If continuation sheet Page 5 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clark-Lindsey Village 101 West Windsor Road Urbana, IL 61801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an allegation of neglect for one (R7) resident out of five residents reviewed for Abuse in a sample list of eight residents. Findings include:R7's Minimum Data Set (MDS) dated [DATE] documents R7 as moderately cognitively impaired. This same MDS documents R7 requires maximum assistance from staff for personal hygiene and is completely dependent on staff for assistance with eating, oral hygiene, toileting, showering, dressing, bed mobility and transfers. The facility is unable to provide documentation of R7's allegation of abuse/neglect on 9/7/25 as being reported to the State Surveying Agency. On 10/14/25 at 10:10 AM, V16 (R7's Power of Attorney/POA) stated the facility is ‘short-staffed'. V16 stated R7 has to wait 30-60 minutes sometimes for staff to answer the call light. V16 stated R7 has cameras placed in her room that record 24 hours per day. V16 stated the personal cameras are reviewed daily and ‘many times' sees that staff do not enter R7's room for multiple hours at a time. V16 stated R7 is incontinent of urine and bowel and needs to be ‘at least changed' (provided incontinence care) every two hours. V16 stated on 9/7/25 V10 and V11 Certified Nursing Assistants/CNAs) assisted R7 to R7's bathroom toilet. V16 stated R7 was being transported from her bed to the toilet using a total body mechanical lift using a toilet sling. V16 stated during the transport back from the toilet to the bed, R7 continued to have a bowel movement. V16 stated R7 was not positioned correctly in the sling and was ‘screaming in pain'. V16 stated R7's entire buttocks and hips were showing below the sling and both of R7's arms were forced above her head due to R7 was sliding out of her sling. V16 stated R7 was about a foot away from the toilet. V16 stated she yelled at the staff (V10, V11) to assist R7 back on the toilet to readjust R7's sling, reduce R7's pain and allow R7 to finish having her bowel movement. V16 stated V11 (CNA) yelled at V16 to ‘get away from us', ‘you need to go sit down' and ‘we (V10, V11) are not moving (R7) anywhere, we know what we are doing, now go sit down'. V16 stated V11 (CNA) then pushed a small garbage can under R7. V16 stated R7 was forced to have a bowel movement in a garbage can as she was screaming in pain due to poor positioning. V16 stated R7 would think this would be ‘absolutely horrid' and be ‘humiliating' to have to have a bowel movement in a garbage can. V16 stated R7 would never have a bowel movement in a garbage can and would be ‘mortified' at this entire incident. V16 stated R7 was ‘hysterical' and ‘afraid' during this transfer back to her bed due to R7 was afraid she was going to fall and was in so much pain. V16 stated V10 and V11 CNAs left R7 on her bed without finishing incontinence care or positioning R7 safely in bed. V16 stated They (V10, V11) just left (R7) there with p*** (expletive) on her. They (V10, V11) walked out of the room and did not come back. V16 stated the facility ‘neglected' R7 by not providing perineal and/or incontinence care, not repositioning R7 for extended periods of time and refused to provide pain relief by not transferring R7 as V16 requested the staff to move R7 to a more comfortable position. V16 stated the staff are ‘belligerent and confrontational' when V16 asked for assistance. V16 stated V15, V17 (R7's private caregivers) and V16 provide direct cares, repositioning, feeding assistance and administer medications to R7 due to the staff are ‘neglectful' by not entering R7's room and force R7's family and caregivers to provide all of the services themselves. V16 stated We (V15, V16, V17) have to do everything for (R7). We (V15, V16, V17) provide all the cares, we administer all of her medications, we reposition (R7), we feed (R7), we provide oral care, nail care, skin care, etc. for (R7). We have to do everything because the staff neglect (R7) on a daily basis. We turn on the call light and no one comes for hours. We have cameras in (R7's) room that shows NO staff enter for six or eight hours or more. Anything (R7) needs, we (V15, V16, V17) have to go get and bring to (R7's) room. We even have to go get her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145381 If continuation sheet Page 6 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clark-Lindsey Village 101 West Windsor Road Urbana, IL 61801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete medications because the nurses won't bring them. V16 stated the facility provided packets and a gallon jug of thickener and a device for V15, V16 and V17 to crush R7's medications. V16 stated the facility allows the staff to neglect R7 by knowing that the staff are not providing R7's cares. V16 stated V16 has had multiple conversations and ongoing electronic mail (E-mail) with V2 (Interim Director of Nursing/DON). V16 stated V16 asked V2 to not have V10 and V11 (CNAs) in R7's room and/or providing any cares for R7 after the 9/7/25 incident. V16 stated both V10 and V11 have provided cares since that date (9/7) and when V2 was informed, V2 responded with ‘(V10, V11) are not (R7's) primary CNAs so that is okay'. V16 stated she asked if there was someone else to speak to about ongoing care concerns and the staff ‘neglecting' R7 and was told by V2 that no one else would be able to do anything. On 10/14/25 at 1:20 PM, V1 (Administrator in Training/AIT) stated she was made aware of R7's family concerns on 9/7/25. V1 stated V2 (Interim Director of Nursing/DON) informed V1 that V2 is ‘taking care of that situation' and nothing else needed to be discussed and/or elevated to a grievance report. V1 stated the allegation of neglect was not reported to the State Surveying Agency. V1 stated all allegations of any type of abuse should be reported and investigated. V1 stated R7's allegation was an isolated incident and has not had any other concerns brought forward by other residents or resident representatives. V1 stated the facility did not follow their abuse policy. On 10/14/25 at 2:40 PM, V2 (Interim DON) stated V16 (R7's Power of Attorney/POA) e-mailed V2 on 9/7/25 reporting V16's concerns and asking for V10 and V11 to not care for R7. V2 stated V10 and V11 (Certified Nursing Assistants/CNA) came to V2 a week after V16 sent V2 an electronic mail (E-mail) on 9/7/25. V2 stated V10 and V11 came to her stating there was an incident on 9/7 involving R7. V2 stated V10 and V11 stated they knew V16 would ‘tattle' on V10 and V11 and they (V10, V11) were reporting themselves. V2 stated V1 (AIT) is still learning the role of Abuse Coordinator so if an allegation would need to be reported to the State Surveying Agency, V2 would be the person to do that. V2 stated she did not report this allegation to the State Surveying Agency.The facility policy dated February 20, 2025 titled Abuse Prevention and Prohibition documents the Administrator or Administrator's designee will report immediately but no later than two hours after the allegation is made to the State Agency if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Event ID: Facility ID: 145381 If continuation sheet Page 7 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clark-Lindsey Village 101 West Windsor Road Urbana, IL 61801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to investigate an allegation of neglect for one (R7) resident out of five residents reviewed for Abuse in a sample list of eight residents. Findings include: R7's Minimum Data Set (MDS) dated [DATE] documents R7 as moderately cognitively impaired. This same MDS documents R7 requires maximum assistance from staff for personal hygiene and is completely dependent on staff for assistance with eating, oral hygiene, toileting, showering, dressing, bed mobility and transfers. The facility is unable to provide documentation of R7's allegation of Abuse/neglect on 9/7/25 as investigated by the facility. On 10/14/25 at 10:10 AM, V16 (R7's Power of Attorney/POA) stated the facility is ‘short-staffed'. V16 stated R7 has to wait 30-60 minutes sometimes for staff to answer the call light. V16 stated R7 has cameras placed in her room that record 24 hours per day. V16 stated the personal cameras are reviewed daily and ‘many times' sees that staff do not enter R7's room for multiple hours at a time. V16 stated R7 is incontinent of urine and bowel and needs to be ‘at least changed' (provided incontinence care) every two hours. V16 stated on 9/7/25 V10 and V11 Certified Nursing Assistants/CNAs) assisted R7 to R7's bathroom toilet. V16 stated R7 was being transported from her bed to the toilet using a total body mechanical lift using a toilet sling. V16 stated during the transport back from the toilet to the bed, R7 continued to have a bowel movement. V16 stated R7 was not positioned correctly in the sling and was ‘screaming in pain'. V16 stated R7's entire buttocks and hips were showing below the sling and both of R7's arms were forced above her head due to R7 was sliding out of her sling. V16 stated R7 was about a foot away from the toilet. V16 stated she yelled at the staff (V10, V11) to assist R7 back on the toilet to readjust R7's sling, reduce R7's pain and allow R7 to finish having her bowel movement. V16 stated V11 (CNA) yelled at V16 to ‘get away from us', ‘you need to go sit down' and ‘we (V10, V11) are not moving (R7) anywhere, we know what we are doing, now go sit down'. V16 stated V11 (CNA) then pushed a small garbage can under R7. V16 stated R7 was forced to have a bowel movement in a garbage can as she was screaming in pain due to poor positioning. V16 stated R7 would think this would be ‘absolutely horrid' and be ‘humiliating' to have to have a bowel movement in a garbage can. V16 stated R7 would never have a bowel movement in a garbage can and would be ‘mortified' at this entire incident. V16 stated R7 was ‘hysterical' and ‘afraid' during this transfer back to her bed due to R7 was afraid she was going to fall and was in so much pain. V16 stated V10 and V11 CNAs left R7 on her bed without finishing incontinence care or positioning R7 safely in bed. V16 stated They (V10, V11) just left (R7) there with p*** (expletive) on her. They (V10, V11) walked out of the room and did not come back. V16 stated the facility ‘neglected' R7 by not providing perineal and/or incontinence care, not repositioning R7 for extended periods of time and refused to provide pain relief by not transferring R7 as V16 requested the staff to move R7 to a more comfortable position. V16 stated the staff are ‘belligerent and confrontational' when V16 asked for assistance. V16 stated V15, V17 (R7's private caregivers) and V16 provide direct cares, repositioning, feeding assistance and administer medications to R7 due to the staff are ‘neglectful' by not entering R7's room and force R7's family and caregivers to provide all of the services themselves. V16 stated We (V15, V16, V17) have to do everything for (R7). We (V15, V16, V17) provide all the cares, we administer all of her medications, we reposition (R7), we feed (R7), we provide oral care, nail care, skin care, etc. for (R7). We have to do everything because the staff neglect (R7) on a daily basis. We turn on the call light and no one comes for hours. We have cameras in (R7's) room that shows NO staff enter for six or eight hours or more. Anything (R7) needs, we (V15, V16, V17) have to go get and bring to (R7's) room. We even have to go get her medications because the nurses won't bring them. V16 stated the facility Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145381 If continuation sheet Page 8 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clark-Lindsey Village 101 West Windsor Road Urbana, IL 61801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete provided packets and a gallon jug of thickener and a device for V15, V16 and V17 to crush R7's medications. V16 stated the facility allows the staff to neglect R7 by knowing that the staff are not providing R7's cares. V16 stated V16 has had multiple conversations and ongoing electronic mail (E-mail) with V2 (Interim Director of Nursing/DON). V16 stated V16 asked V2 to not have V10 and V11 (CNAs) in R7's room and/or providing any cares for R7 after the 9/7/25 incident. V16 stated both V10 and V11 have provided cares since that date (9/7) and when V2 was informed, V2 responded with ‘(V10, V11) are not (R7's) primary CNAs so that is okay'. V16 stated she asked if there was someone else to speak to about ongoing care concerns and the staff ‘neglecting' R7 and was told by V2 that no one else would be able to do anything. On 10/14/25 at 10:20 AM, V16 (R7's Power of Attorney/POA) stated she emailed V2 (Interim Director of Nursing/DON) on 9/7/25 following a ‘terrible incident' between V10 and V11 (Certified Nursing Assistants/CNAs) and R7. V16 stated V2 responded in email to V16 on 9/8/25. V16 stated no one ever came around and interviewed V16 nor V15, V17 (R7's private caregivers) to obtain a witness statement. On 10/14/25 at 3:50 PM, V11 (CNA) stated V10 and V11 reported to V2 (Interim DON) a week after ‘something happened' on 9/7/25. V11 stated V10 and V11 went to V2 due to ‘we (V10, V11) knew that V16 would ‘tattle' on us so, we just talked to V2 ourselves. V11 stated no one had discussed the situation on 9/7 with her prior to that and no one had told her to not be R7's primary caretaker. On 10/14/25 at 1:20 PM, V1 (Administrator in Training/AIT) stated she was made aware of R7's family concerns on 9/7/25. V1 stated V2 (Interim DON) informed V1 that V2 is ‘taking care of that situation' and nothing else needed to be discussed and/or elevated to a grievance report. V1 stated the allegation of neglect was not reported to the State Agency. V1 stated all allegations of any type of abuse should be reported and investigated. V1 stated R7's allegation was an isolated incident and has not had any other concerns brought forward by other residents or resident representatives. V1 stated the facility did not follow their abuse policy.On 10/14/25 at 2:40 PM, V2 (Interim DON) stated V16 (R7's POA) e-mailed V2 on 9/7/25 reporting V16's concerns and asking for V10 and V11 to not care for R7. V2 stated V10 and V11 (CNAs) came to V2 a week after V16 sent V2 an electronic mail (E-mail) on 9/7/25. V2 stated V10 and V11 came to her stating there was an incident on 9/7 involving R7. V2 stated V10 and V11 stated they knew V16 would ‘tattle' on V10 and V11 and they (V10 and V11) were reporting themselves. V2 stated V1 is still learning the role of Abuse Coordinator so if an allegation would need to be reported to the State Agency, V2 would be the person to do that. V2 DON stated she did not report this allegation to the State Agency.The facility policy dated February 20, 2025, titled Abuse Prevention and Prohibition documents when an incident or suspected incident is reported, an investigation will be done immediately. The Administrator will be informed immediately of any suspected incident and/or an injury of unknown origin. The Administrator will appoint someone to initiate and lead an investigation. Event ID: Facility ID: 145381 If continuation sheet Page 9 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clark-Lindsey Village 101 West Windsor Road Urbana, IL 61801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide Licensed Nurses to administer medications on multiple occasions for one (R7) resident out of five residents reviewed for Improper Nursing Care in a sample list of eight residents.Findings include:R7's Minimum Data Set (MDS) dated [DATE] documents R7 as moderately cognitively impaired. This same MDS documents R7 requires maximum assistance from staff for personal hygiene and is completely dependent on staff for assistance with eating, oral hygiene, toileting, showering, dressing, bed mobility and transfers. R7's Physician Order Sheet (POS) dated October 2025 documents physician orders to administer:-Cephalexin 250 milligrams (mg)/5 milliliters (ml) starting 9/26/25 with no end date, give daily for recurrent Urinary Tract Infections (UTI). Prophylaxis for one year.-Cholecalciferol 25 micrograms (mcg). Give two tablets daily.-Lactobacillus Rhamnoses give one capsule daily.-Fluconazole 150 mg tablet daily for Vaginal Candidiasis every three days.-Fluoxetine 10 mg tablet daily-Benefiber packet daily-Lisinopril 40 mg tablet twice daily-Pantoprazole 4 mg/ml suspension give 10 ml daily-Polyethylene Glycol (Miralax) powder 8.5 Grams daily-Prednisone 5 mg tablet daily-Prozac 20 mg tablet daily-Zyrtec 10 mg tablet daily-Acetaminophen 1000 mg tablets twice daily-Carvedilol 12.5 mg tablet twice daily-Diclofenac Sodium 1% external gel. Apply to Left Ankle twice daily.-Lidocaine 5% External patch. Apply to neck in the morning, remove at night.-Memantine 5 mg tablet twice daily-Miconazole Nitrate powder 2%. Apply to vaginal area twice daily.-Potassium Chloride 20 milli equivalents (mEq)/15 ml liquid. Give 15 ml twice daily.On 10/14/25 at 11:10 AM, V15 (R7's private caregiver) left R7's room and returned at 11:20 AM with a medicine cup of a small amount of off-white colored liquid. V15 added 15 milliliters (ml) of liquid thickener that was on R7's bedside dresser, placed the mixture in a syringe and administered R7's Pantoprazole by placing the syringe in R7's Left Buccal area and pushing the syringe so that the medicine was forced into R7's mouth. R7 coughed two times as a small amount of the mixture leaked out of the Left side of R7's mouth. V15 used a tissue to wipe away the medication. R7 had two adaptive cups with lids sitting on her bedside table. There were no medication labels on either cup. V15 stated one of the cups has R7's Miralax and the other cup has R7's Benefiber. V15 stated the nurses tell V15 and the caregivers (V10 and V11) that they do not have time to wait for R7 to take her medications, so they give them to V15 and/or private unlicensed caregivers. V15 stated V15 and private caregivers ‘have to do it this way or (R7) would not get her medications'. On 10/14/25 at 11:20 AM, V15 (R7's private caregiver) stated she is not a Licensed Nurse, does not work for the facility and has had no official training on how to administer medication, how much thickener to use, what the medication side effects are and what medication interactions may be. V15 stated V12 (Registered Nurse/RN) gave her R7's Pantoprazole at the nurse's station. V15 stated this is a daily occurrence because V15 has been told by ‘many' nurses that they (staff) do not have the time to stand and wait on R7 to take her medications due to R7 is a ‘slow swallower'.On 10/14/25 at 12:00 PM, V12 (RN) stated V12 provides medications to V16 (R7's POA) and/or V15 and V17 (R7's private caregivers) so that they (V15, V16, V17) can administer R7's medications. V12 RN stated she gave V15 all R7's medications for 10/14/25 for R7's morning scheduled medications including Benefiber and Miralax as well as R7's scheduled noon medication of Pantoprazole. V12 stated she prepares the medications and the ‘family/caregivers' administer the medications. V12 stated she does not observe R7's POA and/or private caregivers administer R7's medications. V12 stated she was instructed to provide R7's medications to V16 (R7's POA) and/or caregivers by other nurses. V12 stated This is how we (staff) all do it. Our administration approves of this, so I guess it is ok. V12 stated she is not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145381 If continuation sheet Page 10 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clark-Lindsey Village 101 West Windsor Road Urbana, IL 61801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete aware if V15, V16 and/or V17 has any medical knowledge regarding medication administration. On 10/14/25 at 2:25 PM, V2 (Interim Director of Nurses/DON) stated V2 gave approval for V16 (R7's POA) to administer R7's medications without a nurse being present. V2 confirmed V16 and/or V15, V17 (R7) private caregivers are not licensed nurses and are not employed by the facility. On 10/14/25 at 2:50 PM, R7's Benefiber and Miralax were still in the cups sitting on R7's bedside table. The gallon jug of thickener, packets of thickener and pill crusher were still sitting on R7's bedside dresser. V17 (R7's private caregiver) stated R7's Benefiber was ‘stone thick' because it had been sitting too long. V17 stated she administers R7's medications daily and has done so for ‘months'. V17 stated the facility management gave R7's private caregivers and V16 (Power of Attorney/POA) approval to administer R7's medications. V17 stated she is not a licensed nurse and has never had any formal training on medication administration. V16 (R7's) Power of Attorney (POA) stated V20 (Health Services Administration Coordinator) ordered R7's thickener and pill crusher to keep in R7's room due to V16 and R7's private caregivers were ‘bothering' the nurses too much by asking for R7's pills to be crushed and drinks to be thickened. On 10/14/25 at 4:05 PM, V16 (R7's POA) stated V2 emailed V16 on 7/22/25 stating V16 could administer R7's medications without the nurse being present. On 10/15/25 at 9:30 AM, V15 (R7's private caregiver) was assisting R7 to eat R7's breakfast in R7's room. V15 was feeding R7 an orange creamy substance. V15 stated this was R7's Potassium liquid mixed with vanilla ice cream and thickener. V15 stated now the nurses have to mix all of R7's medications. V15 stated R7's adaptive cups contained R7's Miralax and Benefiber. V15 stated We (R7, V15) are working on getting all (R7's) medications down. The staff say they don't have time to stay with (R7). On 10/15/25 at 10:05 AM, V6 (Licensed Practical Nurse/LPN) stated she gave R7's medications to R7 this morning except for R7's Miralax, Benefiber and Potassium. V6 stated she did not have time to wait for R7 to take the Miralax, Benefiber and Potassium due to R7 ‘takes forever to swallow'. V6 stated I would still be in there (R7's room) if I had to do that. I don't have time for that.On 10/15/25 at 4:45 PM, V2 (Interim DON) stated licensed nurses should be administering all medications. V2 stated she did give approval for V16 (R7's POA) to administer R7's medications to make it ‘easier' on the nursing staff. V2 stated the facility will have to review their medication administration policy and educate staff on medication administration. The facility policy dated June 17, 2025, titled General Guidelines for Medication Administration documents the licensed nurse is to identify the resident prior to administering medications. Administer medication and remain with the resident until medication is swallowed. Do not leave a medication in a resident's room without orders to do so. Medications will be administered by legally authorized and trained persons in accordance with applicable State, Local and Federal laws and consistent with accepted standards of practice. Event ID: Facility ID: 145381 If continuation sheet Page 11 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clark-Lindsey Village 101 West Windsor Road Urbana, IL 61801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain accurate medical records for one (R7) resident out of five residents reviewed for Improper Nursing Care in a sample list of eight residents.Findings include: R7's Minimum Data Set (MDS) dated [DATE] documents R7 as moderately cognitively impaired. This same MDS documents R7 requires maximum assistance from staff for personal hygiene and is completely dependent on staff for assistance with eating, oral hygiene, toileting, showering, dressing, bed mobility and transfers. R7's Physician Order Sheet (POS) dated October 2025 documents physician orders to administer:-Cephalexin 250 milligrams (mg)/5 milliliters (ml) starting 9/26/25 with no end date, give daily for recurrent Urinary Tract Infections (UTI). Prophylaxis for one year.-Cholecalciferol 25 micrograms (mcg). Give two tablets daily.-Lactobacillus Rhamnoses give one capsule daily.-Fluconazole 150 mg tablet daily for Vaginal Candidiasis every three days.-Fluoxetine 10 mg tablet daily-Benefiber packet daily-Lisinopril 40 mg tablet twice daily-Pantoprazole 4 mg/ml suspension give 10 ml daily-Polyethylene Glycol (Miralax) powder 8.5 Grams daily-Prednisone 5 mg tablet daily-Prozac 20 mg tablet daily-Zyrtec 10 mg tablet daily-Acetaminophen 1000 mg tablets twice daily-Carvedilol 12.5 mg tablet twice daily-Diclofenac Sodium 1% external gel. Apply to Left Ankle twice daily.-Lidocaine 5% External patch. Apply to neck in the morning, remove at night.-Memantine 5 mg tablet twice daily-Miconazole Nitrate powder 2%. Apply to vaginal area twice daily.-Potassium Chloride 20 milli equivalents (mEq)/15 ml liquid. Give 15 ml twice daily.R7's Medication Administration Record (MAR) dated October 2025 documents V12 (Registered Nurse/RN) and V6 (Licensed Practical Nurse/LPN) administered R7's scheduled daily, and twice daily medications as ordered by the physician. On 10/14/25 at 12:00 PM, V12 (RN) stated V12 signs out medications for R7 that she does not administer. V12 stated she gives R7's medications to V16 (R7's Power of Attorney/POA) and/or R7's private caregivers to administer R7's medications. V12 stated she cannot confirm that R7 receives her medications prior to V12 signing out on R7's MAR as being given. On 10/15/25 at 10:05 AM, V6 (LPN) stated she gives all R7's medications to R7's private caregivers and/or V16 (R7's POA). V6 stated she signs out R7's MAR that R7's medications are being given because she ‘trusts the family to give the meds so I don't have to waste my time doing it'. On 10/15/25 at 4:15 PM, V2 (Interim Director of Nurses/DON) stated the staff should document all the work they do. V2 stated nurses should ensure the resident is receiving the prescribed medications prior to signing off that the medication has been administered. The facility policy dated June 17, 2025, titled General Guidelines for Medication Administration documents the facility nurse should return to the medication cart and document medication administration with documentation in the Medication Administration Record (MAR) immediately after administering medication to each resident. Medications will be administered by legally authorized and trained persons in accordance with applicable State, Local and Federal laws and consistent with accepted standards of practice. Event ID: Facility ID: 145381 If continuation sheet Page 12 of 12